Provider Demographics
NPI:1255992897
Name:CONDER, LAURELL A (NP-C)
Entity type:Individual
Prefix:
First Name:LAURELL
Middle Name:A
Last Name:CONDER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-1100
Mailing Address - Country:US
Mailing Address - Phone:573-717-1072
Mailing Address - Fax:573-559-2289
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848
Practice Address - Country:US
Practice Address - Phone:573-448-3800
Practice Address - Fax:573-448-8909
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR122452363LF0000X
MO2019022745363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420074761Medicaid